Job Summary: Under supervision of the assigned Director, provides comprehensive coordination of care for patients and their families/caregivers, to eliminate barriers to timely care, identifies care needs and refers to appropriate internal and external resources, increases patient, provider and referral source satisfaction, maintains data on interactions and referrals, and serves as the main point of contact for patients and families during normal business hours.

• Receives, reviews and obtains complete information for referrals, including contact with physician’s offices, community agencies, home health agencies, and patients/family members. Uses clinical judgment to evaluate quality of information, medical necessity for home visit and if patient’s needs fit program clinical criteria. Communicates with Manager/Director and/or Medical Director about any patients who do not seem appropriate and communicates final decision to patient/family and referral source.
• Makes welcome calls to patient/caregiver and describes program, informs of insurance coverage and obtains approval to continue process; informs if additional information is needed from the primary care physician before initial visit can be scheduled
• Uses complete referral information to create patient medical record in the electronic medical record and pre-loads known history, medication and other clinical info before provider visit.
• Schedules initial and follow up visits as needed.
• Answers inbound patient/family calls and triages to best resource for needs, including providing patient education when appropriate.
• Uses clinical judgment to assess patient/patient advocate readiness for hospice and clinical status/decline and recommends hospice evaluation when appropriate. Refers patients to hospice for evaluation when requested by patient, family or provider.
• Facilitates access to home health agency of patient/physician choice when skilled needs are identified.
• Refers patients to community resources such as “Area Agency on Aging 1-B” when needed.
• Facilitates referrals from hospice to palliative care for patients graduated for extended prognosis or evaluated and found ineligible.
• Serves as a resource for inquiries about program benefits and criteria.
• Maintains log of daily tasks and prepare weekly, monthly and quarterly reports.
• Documents interactions/interventions in EMR, including messaging primary NP on status.
• Coordinates care with internal and external sources to help patients navigate healthcare system.
• Adheres to the organizational Code of conduct and all departmental and organizational policies, procedures, protocols, practices and all regulatory and legal requirements.
• Adheres to the NorthStar standards to care for every person, every time, 100% of the time.

Qualifications:

• Graduation from an accredited school of nursing with possession of a current license to practice as a registered professional nurse in the State of Michigan.
• Minimum of one (1) to two (2) years of varied nursing experience required; hospice experience and CHPN preferred.
• Ability to use technology (hardware and software) required of clinicians to use in their practice.
• Must be able to read, write and speak English fluently and be able to effectively communicate orally and in writing in internal and external relationships for all essential job functions.
• Must possess sound judgment and demonstrate strong critical thinking skills and possess the ability to function under stress.
• Demonstrated ability to organize, prioritize and manage multiple, competing priorities with great attention to detail, accuracy, tact, and ability to maintain confidential information.
• Must demonstrate ability to maintain accountability and work independently and creatively while functioning as part of a cooperative, coordinated team
• Must be able to cope with family/caregiver emotional stress, cultural diversity and be tolerant of individual life-styles.
• The physical demands of the position include: vision, effective speech and hearing for extensive telephone contact; repetitive motion; traveling; driving or riding in motor vehicle for extended periods; standing, sitting, walking, bending, reaching, and stretching; lifting up to forty five (45) pounds unassisted and the ability to assist in lifting patients using appropriate lifting techniques and/or devices.
• Must have the ability to occasionally work extended days, as necessary.
• Must have reliable transportation.
• Must be eligible to work in the United States.